What is the best course of action for an 8-month-old COVID-19 positive child with croup, who has received two doses of dexamethasone and requires frequent epinephrine (adrenaline) nebulizations, despite having no fever and normal eating and drinking habits?

Management of COVID-19 Positive Infant with Persistent Croup

The 8-month-old COVID-19 positive infant with persistent croup symptoms despite two doses of dexamethasone requires escalation of therapy with additional dexamethasone and consideration for hospitalization until resolution of resting stridor.

Current Clinical Situation Assessment

This infant presents with:

• Day 4 of croup
• Persistent resting stridor (concerning sign)
• COVID-19 positive
• Two doses of dexamethasone already administered
• Requiring 3-4 epinephrine nebulizations daily
• No fever
• Good oral intake (eating and drinking well)

Management Algorithm

1. Immediate Interventions

• Continue respiratory support:
  • Administer additional dexamethasone at 0.6 mg/kg orally 1
  • Continue racemic epinephrine nebulizations as needed for stridor 2, 3
  • Maintain humidified oxygen if oxygen saturation falls below 94% 4

2. Hospitalization Decision

• Continued hospitalization is indicated due to:
  • Presence of resting stridor (indicates moderate-severe airway obstruction)
  • High frequency of epinephrine nebulization requirements (3-4 times daily)
  • COVID-19 positive status requiring monitoring for potential deterioration
  • Day 4 of illness with persistent symptoms despite standard therapy

3. Medication Management

• Dexamethasone:

  • Administer a third dose of dexamethasone 0.6 mg/kg 1
  • Consider extending the course to a total of 3-5 days given the persistent symptoms 2

• Racemic epinephrine:

  • Continue as needed for stridor, maintaining careful observation for 1-2 hours after each administration
  • Monitor for tachycardia and other side effects 3, 5

4. Monitoring Parameters

• Respiratory status:

  • Continuous monitoring of respiratory rate, work of breathing, and oxygen saturation
  • Frequent assessment for stridor at rest and with agitation
  • Monitor for signs of respiratory fatigue or deterioration

• COVID-19 monitoring:

  • Monitor for development of fever or other COVID-19 symptoms
  • Observe for signs of hyperinflammation (though this appears to be standard croup rather than MIS-C based on current presentation) 6

5. Discharge Criteria

The patient can be considered for discharge when:

• No stridor at rest for at least 24 hours
• Reduced or no need for racemic epinephrine for at least 12-24 hours
• Maintaining adequate oral hydration
• Parents/caregivers educated about warning signs requiring return to hospital

Special Considerations for COVID-19 Positive Status

While the primary presentation is croup, the COVID-19 positive status requires additional attention:

• The American Academy of Pediatrics identifies that most children with COVID-19 have mild symptoms, but monitoring is essential 4
• Continue glucocorticoids as indicated for croup management, as they are appropriate even in the setting of COVID-19 6
• Monitor for development of MIS-C symptoms, although this typically presents 2-6 weeks after acute COVID-19 infection 4

Common Pitfalls to Avoid

1. Premature discharge: Patients with resting stridor should not be discharged, as this indicates significant airway obstruction that could rapidly worsen.

2. Inadequate steroid dosing: Ensure full therapeutic dosing of dexamethasone (0.6 mg/kg) rather than lower doses, as higher doses are more effective for persistent symptoms 1.

3. Failure to recognize deterioration: Despite good oral intake and absence of fever, persistent resting stridor indicates significant airway compromise requiring continued close observation.

4. Overreliance on epinephrine: While epinephrine provides temporary relief, the frequency of administration (3-4 times daily) indicates inadequate control with current therapy and the need for additional interventions.

5. Overlooking COVID-19 complications: Although presenting primarily as croup, monitoring for evolving COVID-19 manifestations is essential, particularly in an infant this young 6, 4.